Why Clinical Alarms Are a ‘Top Ten’ Hazard: How You Can Help Reduce the Risk

Abstract

devices and systems with alarms. You’ll find them on infusion pumps, physiologic monitors, ventilators, anesthesia machines, dialysis units, laparoscopic insufflators, and so on. It’s amazing how much the healthcare system has grown to rely on medical device alarms. It would be hard to walk into almost any type of patient room or care area and not find an alarm-based device being used. In critical care areas, it’s typical to find a dozen or more such devices, just for one patient. And these devices are now starting to become interconnected and are sharing lots of critical information, including alarm data. With such widespread use of alarm-based medical devices, you’d think we would have a very effective safety net to warn about serious changes in patient conditions or performanceand safety-related problems with devices. Unfortunately, as many experts agree, there are serious problems with the design and use of device-based clinical alarms. Clinical alarms have been at or near the top of the ECRI Institute’s list of “Top 10 Health Technology Hazards” since the annual list was first published in 2007. It remains near the top because alarm-related events are all too common, and the consequence of these problems can be extremely serious.1,2 Alarm Fatigue and Confusion In early 2010 The Boston Globe reported on a typical alarm-related problem in which a patient’s death may have been due to a critical physiologic monitoring alarm being turned off. That incident was attributed to alarm fatigue, in which caregivers can become overwhelmed by the sheer number of alarms.3 Alarm fatigue can cause caregivers to unsafely modify alarm settings or silence alarms in order to reduce alarm overload. Or, caregivers can become desensitized to alarms and miss or delay their response to critical patient events.4 When you do your look around the hospital, consider how many different types of medical device alarm settings are being used.5 Often, two different models of the same device type can have slightly different ways to set the same type of alarm. This can confuse caregivers who have to operate and adjust alarms for both models. ECRI Institute has investigated alarm-related incidents in which this type of confusion has had fatal consequences. The risk of this happening is magnified when you consider that many devices have multiple alarms, often with several different ways to adjust them. Most medical devices with clinical alarms are intended for use on a variety of patients with a variety of medical conditions. As such, their alarm limits and other parameters are adjustable to meet the needs of the many types of Why Clinical Alarms Are a ‘Top Ten’ Hazard How You Can Help Reduce the Risk